Do Physicians Have the Time for Quality?

This week's mixed-bag news item comes from a study that found primary care physicians have been spending more time—and not less, as anticipated—with their adult patients compared to a decade ago.

That's good news for patients—and very surprising in light of the reimbursement system that pays primary care physicians proportionately less than other physicians.

However, the corresponding gains made in quality improvement remained sometimes modest, or even flat, for many of those physicians.

Previous studies have suggested that "significant investments of primary care physician time" may be required to deliver high quality care, said researcher Lena Chen, MD, of the University of Michigan Health System in Ann Arbor, in the study that appears this week in the Archives of Internal Medicine.

So Chen and her colleagues went out to find whether "efforts to improve efficiency" might have a detrimental effect on quality of care at the visit level. They started by conducting a retrospective analysis of visits by adults 18 years or older to a nationally representative sample of office based primary care physicians in the U.S.

What they found was that between 1997 and 2005, adult primary care visits in the US increased from 273 million to 338 million annually—or 10% on a per capita basis. At the same time, the mean visit duration increased from 18.0 to 20.8 minutes.

Visit durations increased by 3.4 minutes for general medical examinations and for the three most common primary diagnoses of diabetes mellitus (4.2 minutes), essential hypertension (3.7 minutes), and arthropathies (5.9 minutes). Comparing the early period (1997 2001) with the late period (2002 2005), quality of care appeared to improve for one of three counseling or screening indicators and for four of six medication indicators.

Providing appropriate counseling or screening generally took 2.6 minutes for diet, 2.7 minutes for blood pressure check, and 4.2 minutes for exercise counseling. Providing appropriate medication therapy, however, was not associated with longer visit duration.

On average, visits with general internists were 1.7 minutes longer than those visits with family or general practitioners. Other characteristics, though, such as practice location in a metropolitan area and physician ownership of the practice, were not associated with differences in duration.

Overall, in regard to patient factors, older patients had longer visits—18.4 minutes for those 76 or older—compared with 16.7 minutes for those ages 18 to 35.

The findings suggest that the relationship between visit duration and quality of care depend on the type of quality indicator.

Overall performance on clinical quality metrics was poor. Better performance on medication quality measures did not seem to require extra physician time, while better performance on counseling or screening indicators was associated with longer visit duration.

"Improvements in quality of care will likely require a combination of investments in systems, such as electronic health records, greater use of other professionals, such as nurse practitioners, and better reimbursement to primary care physicians for the extra time spent," they concluded.